Those Who Need It Most

The Orang Asli, the indigenous people of Peninsular Malaysia, number less than 150,000 people nationwide, making them one of the smallest ethnic groups in the country. They are also one of the most vulnerable. A third of Orang Asli fall below the poverty line, making less than RM 6.50 a day; 15.4% of Orang Asli subsist on less than half that sum. They lag far behind in immunization coverage and educational attainment, yet lead the pack in maternal and child mortality. Diabetes, high blood pressure, and malnutrition are rampant in Orang Asli settlements, yet access to healthcare is notoriously poor.

An Orang Asli family preparing a meal in traditional bamboo tubes.

Boots on the Ground

An essential part of medical education is to learn firsthand the challenge of delivering healthcare to these overlooked people groups in our country like the Orang Asli. On the 7th of November 2015, we participated in a health screening program at the nearby Orang Asli village of Simpang Arang. Forty three of us took off from NUMed at about half past eight, bringing with us a few carloads of tables, chairs, and medical supplies.

Four clinical lecturers had volunteered their time to provide expert consultation for villagers deemed to be ‘high risk,’ whilst a medical team from the nearby community clinic provided a separate screening for dental health and hygiene as well.

Located along a tributary of the Pulai river, Simpang Arang is accessible only by a one-lane dirt road just off the main road in Gelang Patah—a road so narrow you have to stop completely for oncoming traffic. We passed by plantations and fields, driving under the shade of the forest reserve, as we drove single-file toward the village center. More than a few farmers stopped their work briefly, staring bemusedly at the long procession of cars ambling into the village.

At about nine o’clock, we assembled at the site of our health camp, an old religious school. The village head greeted us at the gate, and gave us a short tour of the site.

Setting Things Up

The school had not been used for years, and it showed. Mutilated, termite-eaten desks littered the hall and corridors, and dust billowed from every seam and crack in the woodwork as we cleared the hall and swept the floor clean.

We wiped down every piece of furniture, mopped the floor, and cleaned out the drain—by ten, the place was clean enough for us to start arranging the tables and bring in the medical equipment. At half past ten, we officially opened our makeshift health screening center to the public.

The setup was simple. We would use the main hall of the school for the adult health screening; visitors would register at the front counter, before having their body mass index (BMI) calculated from their height and weight.

At the next station, they would have their blood pressure and blood sugar measured and recorded. If either of those measurements were cause for concern, we would direct the visitor to one of our clinical lecturers for further referral and consultation; if not, they would receive a short presentation on healthy eating, exercise, and stopping smoking, from one of our volunteers. At-risk villagers would be ultimately referred to the local community clinic, to be more extensively assessed and treated. As a parting token of thanks—and an incentive for other would-be visitors—we would provide a small gift pack of nasi lemak (a fragrant rice dish) and a drink packet.

At the canteen, a separate health screening would be conducted for children, where volunteers would plot their height and weight on standardized growth charts. Our aim was to identify children who were not growing as well as they should for their age—malnutrition was startlingly common among Orang Asli children. These also would be referred to the community clinic, both for a comprehensive pediatric assessment as well as social services. The community clinic team would set up a separate station for dental health screening, including a short consultation on proper dental hygiene.

Right Down to Work

Our first visitors trickled in. Many of them were curious children who happened to be playing nearby, and were intrigued by the sudden buzz of activity around the old school. We played football with some of them, spent time chatting with others, and managed to convince a few intrepid ones to take part in our pediatric screening. Eventually, inquisitive youngsters dragged in inquisitive parents, and we had our first adult visitors.

By eleven, the trickle of incoming villagers had started to swell, and we were getting busy in earnest. Our volunteers worked in shifts at the stations measuring blood pressure and blood sugar, taking turns at hourly or half-hourly intervals. Chairs were set up in the middle of the hall, creating a makeshift waiting area. Eventually the chairs were perpetually filled—villagers were coming in as quickly as we could process them.

A volunteer measuring the blood pressure of a villager.

For many of us, it was our first contact with a rural community within the healthcare setting. For many of them, it was their first meeting with anyone medical in months—for some, years; for a few, their first ever health checkup. Quite a few fidgeted in their seats and fiddled nervously with the leaflets in their hands. Some older villagers smiled at us and struck up small talk.

Getting to Know Them

Many memorable encounters were born from those few hours we spent in that old hall. We found time for conversation in the few minutes we shared with our guests, while putting blood pressure cuffs on thick, leather-skinned arms and spearing calloused fingers with medical lancets. They talked of their work—setting off into the river on sampans before the roosters had even begun crowing, or working in the plantations well into the evening, braving the sun and the insects. Not many owned vehicles. Some had owned the same pair of work shoes for years.

They discussed their health. Very few visited a clinic regularly—very few, indeed, had the time. For a villager making on average less than two hundred ringgit a month, a day off for a clinic appointment was a luxury not often afforded. An astounding number were diabetic, and the complications were starting to show in more than a few—they complained of numb feet and aching joints, worsening eyesight, and frequent tiredness. Those we referred to our doctors for further consultation.

What struck us most, though, was how genuinely grateful many of them felt. For quite a number of them, the health camp was a novel experience; it was rare to see so many doctors (medical students, we insisted kindly) congregating on their village to inquire about their health. They expressed their feelings earnestly.

“You’re all so polite.” An elderly fisherman grinned at me through yellow-brown teeth as I put on the blood pressure cuff. “Doctors today are so polite. Back in the day I met lots of rude ones. You’re not like that at all.”

Others were worried, and it was plain to see. “They said my blood pressure’s high. They’re asking me to come here and have it taken again,” said a young man of sixteen, fidgeting in his seat. “Am I going to be alright? Please tell me I’m okay.”

I couldn’t. But I measured his blood pressure anyway and directed him to a doctor that could. For what it’s worth, I saw his expression relax as he spoke to one of our clinicians—hopefully replacing his trepidation with clarity.

Watching, Learning, Doing

We learned much. We observed how our doctors communicated with the anxious patients referred to their stations. They spoke to their patients gently, explained concepts in simple words, used down-to-earth analogies when talking about disease—and yet they managed to communicate all that the patient needed to know. They answered their patients’ questions clearly: what’s wrong with me, what’s going to happen, what should I do. No unintelligible jargon, no verbose commentary. Many of their charges were barely literate—and yet we saw heads nodding in understanding. More importantly, we witnessed rapport and trust between doctor and patient, extending across the boundaries of education and socioeconomic inequality. All in the time it takes to complete an OSCE station. In the background, observing the superior skill of our mentors, we took notes.

We gleaned what we could about the people who were both our guests and our hosts, from watching and from listening. Outside, children played with deflated footballs on a field that till a few hours ago was dotted with garbage. A disheveled man limped in barefoot, his dirty shirt lopsided on one shoulder, looking around inquisitively before walking back out. These people lived only ten minutes off the highway, yet were nearly a world—and several income brackets—removed from us, experiencing challenges and problems inconceivable to urban folk.

We tried to distill our experiences and realise the enormity of community medicine, the challenge of fully understanding the people to whom we administer medicine. William Osler once said that there is no more difficult art to acquire than the art of observation—to objectively describe what you were really looking at. But try we did—and learn we did.

We wrapped up at half past two; by then very few were left in the hall except for a few stragglers interested in the leftover nasi lemak. The crowd gathering outside the hall, however, was there for a very different reason. A friendly competition between our best and theirs—a tug of war!

A Test of Strength

Their team was already chomping at the bit. Young men and middle-aged, flexing their arms and grinning appraisingly at our own guys as they lined up at the other end of the rope. A sizeable audience had gathered at the field just outside the school. It was now obvious that despite our best efforts, this—rather than the health camp—was the main attraction of the day as far as they were concerned.

We have some chance.

Alright. We have no chance.

The tug of war began at a quarter to three. The participants gripped the rope, the whistle blew—and our strong NUMed men went flying across the field. It took three seconds. Three seconds for the villagers to utterly dominate the game and drag our best contenders halfway across the field. Didn’t matter that half our guys went to the gym regularly—there was no way any of us could compete with men who hauled felled logs and trawled nets every single day. There was a second round this time between our female volunteers and their women—we lost that one too. Still, seeing the grins and light-hearted ribbing from the villagers made the experience more than worthwhile.

Saying Goodbye

We finally concluded the health camp at three o’clock, after a quick debriefing from our team leader Tay Jia Chyi and an appreciative word from the village head. There were a few kind words exchanged with the villagers who lingered around the now-empty hall. Many volunteers shared a final moment of joy with the children, to whom we were new friends and playmates for a day.

Wrapping up…

We went back down that one-lane road, single file. The trees and oil palms disappeared behind a road divider—and that was it. Back to Nusajaya, back to the heartbeat of Johor’s relentless urban development, both ten minutes and a world away from Simpang Arang.

The Inverse Care Law and Other Things

I’d like to think that we managed to make a difference during those few hours we spent speaking to people whom we wouldn’t otherwise meet. In hindsight, the blood pressure measurements, the glucose numbers, the body mass indexes, the lifestyle advice and posters and charts—the works—seem almost like an afterthought. True enough, we contributed to their health awareness, or hoped that we did. But those completed A6 forms we handed them stand as much chance of lying discarded under next week’s groceries as they do of being taken to the community clinic to aid in the follow-up. Our health camp was in the end a one-time operation, a touch-and-go, and without following up on the village over the next week, or month, or year—it’s difficult to truly assess our long-term impact on their health.

I prefer to end on a less cynical note. The health camp was hugely beneficial—to us, to the future healthcare professionals that would someday minister to the same villagers we met. Our brief foray into Simpang Arang should serve as a reminder that we are called to serve people from all walks of life, and that not all people suffer ill health equally.

Julian Tudor Hart compared health to champagne: “Rich people get lots of it. Poor people don’t get any of it.” Like wine, then, health dribbles turbulently down the socioeconomic strata, its flow drying up the further down the social ladder it goes. And it is those who sample its terminal dregs—the abject poor, illiterate, invisible, or geographically removed—in short, the “hard-to-reach” groups which need it most, that experience the worst health of all.

We should be made aware that healthcare coverage is often porous, and it is those seemingly invisible groups that slip through the cracks that suffer the worst health. Someday, we will treat real patients. We will run clinics. We will write policy. In that time, we should seek not just to sharpen the cutting edge of medicine, but to ensure that it is delivered to all strata of society—especially those that need it most.